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Debating Best Surgical Technique for Trigeminal Neuralgia

October 3, 2014
A new study raises questions about the cost-effectiveness of surgical procedures to manage trigeminal neuralgia, a chronic debilitating condition that affects the trigeminal nerve, causing bouts of intense facial pain.

Trigeminal neuralgia (TN) is a debilitating chronic pain condition affecting the trigeminal nerve, where patients experience intense facial pain, which can become intractable.

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As practitioners continue to investigate the efficacy of various ways to treat this condition, a team of researchers recently published a study in the 7

They concluded that one of these procedures, percutaneous stereotaxic rhizotomy (PSR) was not only the most cost-effective but also the least utilized, compared to other far more expensive treatments, such as microvascular decompression (MVD) and stereotaxic radiosurgery (SRS).

How the Study Was Performed

The researchers, led by Sananthan Sivakanthan, MD, from the Morsani College of Medicine at the University of South Florida in Tampa, looked at 1,582 cases of TN culled from 2011 Medicare claim data to assess the usage, cost, and effectiveness of MVD, SRS, and PSR. Of the patients that had a surgical intervention, 51.1% underwent MVD, a nonablative procedure, 41.5% were treated with SRS, a noninvasive yet ablative option, and 7.4% underwent  PSR.

The researchers found the most utilized procedures were also the most costly—MVD and SRS had average weighted costs of $40,434.95 and $38,062.27, respectively. PSR, of the other hand, cost about a 10th of the other procedures, $3,910.64. But lower cost does not always mean better results. In fact, the researchers found that MVD, the most costly procedure, also had the most quality-adjusted life years (QALY) score, as defined as complete freedom of pain, not including facial numbness or a partial reduction in pain symptoms. The QALY was 8.2 for MVD, 6.5 for PSR, and 4.9 for SRS.

Why is PSR Not Performed More Often?

The study has sparked questions as to why PSR is so infrequently utilized, despite its effectiveness and low cost. 

"It becomes a vicious circle where not many surgeons are comfortable with the procedure, therefore it is not used or taught very often, and less and less surgeons are comfortable with it," Dr. Agazzi said. He noted that he was surprised MVD was so prevalent, but said that MVD is a very effective treatment for reducing pain without causing facial numbness.

"Numbness can be quite bothersome to some patients in particular if the numbness is very dense," Dr. Agazzi said, mentioning that "pain and numbness both participate in the quality of life," while the recent study did not factor numbness into the QALY calculations.

MVD Still Preferred Technique

Steven Graff-Radford, MD, treats TN extensively at the Cedars-Sinai Pain Center in Los Angeles, California, and currently serves on the board of the Trigeminal Neuralgia Association. According to Dr. Graff-Radford, the most successful surgical procedure has consistently been MVD.8-13

He mentioned his experiences with SRS and PSR, which were discontinued at Cedars-Sinai because of complications. In particular, while the SRS procedure, utilizing the Gamma Knife tool, was "exceptionally effective," 4 out of 16 patients experienced worsening symptoms.

PSR procedures also had their own worrisome complications, where a marked percentage of patients experienced anesthesia dolorosa, a condition in which the affected area is struck with severe pain while being numb to the touch. Classified as Trigeminal Deafferentation Pain (TDP), it's been known to occur after ablative denervating procedures, like PSR.

While the rate of TDP and other problems aren't very high, past literature has shown PSR to be noticeably ineffective in the long-term,7, 14-17 which may explain why practitioners like Dr. Graff-Radford endorse the MVD treatment modality over the others.

The authors of the study have no financial information to disclose. 

Last updated on: May 18, 2015